Healthcare Provider Details

I. General information

NPI: 1376067496
Provider Name (Legal Business Name): SHANNON SHAH NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2017
Last Update Date: 05/05/2025
Certification Date: 05/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 ENGLE ST
ENGLEWOOD NJ
07631-1808
US

IV. Provider business mailing address

155 CRYSTAL RUN RD
MIDDLETOWN NY
10941-4028
US

V. Phone/Fax

Practice location:
  • Phone: 201-894-3636
  • Fax:
Mailing address:
  • Phone: 845-703-6999
  • Fax: 845-703-6297

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF308256
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number26NJ00913700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: